You might have had the experience of going to a beautiful restaurant and having terrible service. What did you tell your friends about the restaurant?

Excellent healthcare can be provided in the most depressing surroundings—and the patient will remember the excellent care. When poor care is delivered in a beautiful surrounding, the patient will remember the poor care.

The moral of all this is that service counts more than surroundings. A beautiful setting cannot overcome a surly or incompetent staff; but a cheerful, capable caregiver can overcome a lack of facility ambience. A well-designed facility cannot provide an excellent experience or a lasting relationship. It can only supply a tool to be used by caregivers to accomplish those goals. However, consider this: Happy environments promote happy caregivers. It just may be that the environment's role is just as important—perhaps even more important—in providing support for caregivers as for patients. The reason is simple: It is easier to provide care in a well-designed facility. When a task is made easier, or more enjoyable, caregivers become happier.

You've probably guessed where this is going: It is at least as important to create excellent environments in the “back rooms of the house” as it is in the “parlor.” Doing so promotes staff pride and enthusiasm, and can be an effective retention and recruitment measure.

We can create the environment, but people make it work. It is obvious that concern for the patient flows through caregivers, not from the wallpaper. Perhaps, then, Architecture's greatest contribution to patient well-being is to create environments that support staff and family—in other words, the caregivers.

We must enhance caregivers’ working environments to reduce stress, promote communication, provide respite, reinforce spirituality, save time, and (in answer to a universal request) provide adequately sized, usably designed, and appropriately located storage. We must try to eliminate every physical, psychological, and emotional barrier caregivers face in the discharge of their duties.

Studies have demonstrated that well-designed patient environments contribute to faster recovery and better outcomes. This remarkable correlation no doubt depends a great deal on the fact that the enhanced environment influences caregivers, as well as patients. If we acknowledge that environment has a positive or negative influence on individuals, it probably follows that the degree to which one is influenced is directly proportional to length of time spent in the environment. Which leads to another major point: Patients come and go, but caregivers remain forever.

Much has been written about a “front room/back room” or “on-stage/backstage” design philosophy which, by definition, divides the focus of healthcare facility design into two categories. Certainly there are vast differences in functional design requirements between the main lobby and a nurses’ lounge—but should there be a difference between them in the environmental ambience expressed, or the effort expended to achieve it, or the quality of the experience generated by the room? Is it more important to impress our guests than to satisfy our family?

It is interesting to note that our living rooms are usually the showcase of our homes, while we actually live in the family room, or the kitchen, or the den. Although we entertain our guests in the living room, we actually live in another, more comfortable part of the house. We're seeking comfort. Where is finding comfort more important, and so difficult to find, than in a hospital?

In order to design for comfort, it is instructive to analyze what can disrupt comfort. The following will significantly reduce the comfort level of any surrounding:

  • Persistent, aggravating sounds

  • Shiny surfaces

  • Poorly controlled lighting

  • No ready view of the exit

  • No view of the outside

  • Sterile or austere furnishings

  • Seeing strangers who can presumably also see us

  • Accent colors, if they are not our colors

  • Small spaces to put our “stuff”

  • Temperature excess (either way)

  • Odd smells

  • Lack of privacy

Knowing the importance of comfort, why do we find so many hospital environments to be so disquieting? There are several reasons—none of them valid. In sum, issues of infection control, security, regulatory compliance, and presumed space efficiency (thought, wrongly, to be equivalent to cost efficiency) tend to lead designers to create fairly Spartan environments. Also, many architects who are drawn to hospital design are attracted to it for that very reason: a chance, in their view, to exercise a Spartan design philosophy, sometimes summarized as “less is more.” (In fact, it isn't.) Another chilling architectural mantra describes buildings as “machines for living”; this has a certain clang to it for high-tech healthcare, but it is a rather depressing analogy for one seeking an environment offering comfort, solace, and hope.

The point of this detour into traditional healthcare design principles is to point out that the level of success achieved in designing a caring environment depends quite heavily on the architect's philosophy. Those wishing to develop a truly health-giving environment should choose an architect who understands that words like decoration, playfulness, celebration, diversity, homelike, and noninstitutional are positive expressions of Architecture, not impediments to creating a proper machine for living.

So, what specifically can we do for caregivers? Here are some suggestions, not necessarily original but appearing new, perhaps, when framed from the perspective of caregivers. For example, one's initial experience upon approaching a hospital is influenced not only by the wayfinding arrangements, landscaping, and external appearance, but also by the parking arrangements. Courtesy parking for everyone, including caregivers, should be seriously considered. A cadre of fleet-footed parking attendants can stack more cars in less space than the public can by groping for elusive parking stalls. Cars can be “triaged” as to physician, staff, visitor, vendor, patient, etc. Parking security can be increased. No more walking the length of a football field in the rain trying to remember where you parked. Everyone becomes happier—except, perhaps, the organization's CFO (cost) and Risk Manager (liability).

But let's get serious. The cost of something like this is infinitesimal in the vast wasteland of hospital operational expenses. No, there is no direct return on investment (the beloved ROI)—except happier people. As for liability, if my favorite restaurant can accept the risk of valet parking, why would an industry that routinely kills 150,000 people a year via “medical errors” view car-parking arrangements with such alarm?

One of the arguments we have heard advanced against courtesy parking is that it would have to operate 24/7/365. Those advancing that argument apparently have not had to walk into a dark parking garage at 3 a.m. If caregivers can't be given courtesy parking, let's at least give them a secured card-access parking area for “employees only,” with its own surveillance, waiting shelter, and regularly scheduled, dependable van pickup.

Next idea: Does a private dining area for caregivers make sense? Such a space can provide a place for them to unwind “off-stage,” have conversations about patients without violating HIPAA, and foster a collegial environment with their fellow caregivers. If it is good for doctors to have private dining, why not for the extended caregiver system that supports them?

I hear that CFO muttering about cost again. It is important, therefore, to understand the magnitude of the cost we are talking about. The financing of a typical hospital building will result in a mortgage payment that will approximate 4% of the hospital's total operating expenses. That 4% can greatly impact the other 96%. Isn't it worth investing in the 4% for things that can decrease the 96%? If the cost of caregiver recruitment, retention, and payroll can be reduced, for example, we are making a positive impact on the largest single source of operational costs—the maintenance of staff.

Some more ideas (and costs) to think about: To achieve a quieter environment, we could upgrade standard acoustic ceilings from being merely cosmetic to having actual acoustic properties. The cost of the interior finishes of a hospital is approximately 14% of total construction costs. The cost of the ceiling is approximately 8% of the 14%. The cost to upgrade the ceiling is an increase of approximately 20%, i.e., an increase from 8% to 9.6%. Against a total construction cost of $50 million financed at 4% over 30 years, the cost for the ceiling upgrade will approximate $530 per year.

So, let's take a realistic approach to allocation of our design dollars by realizing that not every dollar need offer a monetary return on investment. Maybe caregiver satisfaction, improved recruitment and retention, and excellent job performance, with fewer medical errors, will be viewed in their own right as ROI of the most basic kind for a facility providing healthcare. HD

Nick Devenney, AIA, ACHA, is the founder of Devenney Group, Ltd., a Phoenix-based architectural firm founded in 1962 that specializes in the design and development of healthcare and research facilities. He has been a leading architect in his field for more than 40 years.